Download PDF
J Neurol Surg A Cent Eur Neurosurg
DOI: 10.1055/a-2200-3674
Original Article

Decompressive Bone Flap Replacement (Decompressive Cranioplasty): A Novel Technique for Intracranial Hypertension—Initial Experience and Outcome

Junhua Ye
1   Department of Neurosurgery, Meizhou People's Hospital, Meizhou, China
,
Mingli Liang
1   Department of Neurosurgery, Meizhou People's Hospital, Meizhou, China
,
Qizheng Qiu
1   Department of Neurosurgery, Meizhou People's Hospital, Meizhou, China
,
Wenbo Zhang
1   Department of Neurosurgery, Meizhou People's Hospital, Meizhou, China
,
Min Ye
1   Department of Neurosurgery, Meizhou People's Hospital, Meizhou, China
› Author Affiliations Funding This work was supported by the Research and Cultivation Project of Meizhou People's Hospital (no. PY-C2019024).
› Further Information
    Permissions and Reprints

Abstract

Background Intracranial hypertension is a life-threatening condition that can be treated by decompressive craniectomy (DC), which involves removing a part of the skull and intracranial lesions. However, DC has many complications and requires a second surgery to repair the skull. Decompressive bone flap replacement (DBFR) or decompressive cranioplasty is a novel technique that replaces the bone flap with a titanium mesh, providing both decompression and skull integrity.

Methods The materials and methods of DBFR are described in detail. A three-dimensional titanium mesh is fabricated based on the computed tomography (CT) data of previous DC patients. An appropriate titanium mesh is selected based on the preoperative and intraoperative assessments. After removing the intracranial lesions, the titanium mesh is fixed over the bone window.

Results We successfully performed DBFR in three emergent cases. The postoperative CT scan showed adequate decompression in all cases. No reoperation for skull repair was needed, and there were no surgical complications. The cosmetic outcome was excellent. There were no relevant complications in the operative area.

Conclusions DBFR may be a safe and effective alternative to DC in a specific subgroup of patients, in whom complete removal of the bone flap is feasible. DBFR can reduce intracranial pressure while maintaining the integrity of the skull cavity, eliminating the need for additional surgery for skull repair. Possible improvements for DBFR in the future are suggested, such as using a greater curvature of the titanium mesh or a modified DBFR with a hinged titanium mesh.

Keywords

decompressive bone flap replacement - decompressive cranioplasty - intracranial hypertension

Ethical Approval

The study was approved by the institutional review board.


Author Contributions

J.Y. was responsible for conception and design of the study, and drafting of the article. J.Y., W.Z., and Q.Q. performed the operation. M.L. was responsible for acquisition of data and critically revising the article. All the authors supervised the study and reviewed the submitted version of the manuscript. M.Y. approved the final version of the manuscript on behalf of the authors.




Publication History

Received: 17 July 2023

Accepted: 24 October 2023

Accepted Manuscript online:
27 October 2023

Article published online:
12 February 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Carney N, Totten AM, O'Reilly C. et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurg 2017; 80 (01) 6-15
    Google Scholar
  • 2 Smith M. Refractory intracranial hypertension: the role of decompressive craniectomy. Anesth Analg 2017; 125 (06) 1999-2008
    Google Scholar
  • 3 Jüttler E, Schellinger PD, Aschoff A, Zweckberger K, Unterberg A, Hacke W. Clinical review: therapy for refractory intracranial hypertension in ischaemic stroke. Crit Care 2007; 11 (05) 231
    Google Scholar
  • 4 Yang CH, Li Q, Wu C, Ma JP, You C. Decompressive craniectomy or not: intraoperative experience in 41 patients with severe traumatic brain injury. Chin J Traumatol 2012; 15 (03) 158-161
    Google Scholar
  • 5 Huang X, Wen L. Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury. Int J Med Sci 2010; 7 (06) 385-390
    Google Scholar
  • 6 Phan K, Moore JM, Griessenauer C. et al. Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis. World Neurosurg 2017; 101: 677-685.e2
    Google Scholar
  • 7 Honeybul S, Ho KM. Decompressive craniectomy for severe traumatic brain injury: the relationship between surgical complications and the prediction of an unfavourable outcome. Injury 2014; 45 (09) 1332-1339
    Google Scholar
  • 8 Shimamura N, Munakata A, Naraoka M, Nakano T, Ohkuma H. Decompressive hemi-craniectomy is not necessary to rescue supratentorial hypertensive intracerebral hemorrhage patients: consecutive single-center experience. Acta Neurochir Suppl (Wien) 2011; 111: 415-419
    Google Scholar
  • 9 Tsermoulas G, Shah O, Wijesinghe HE, Silva AHD, Ramalingam SK, Belli A. Surgery for acute subdural hematoma: replace or remove the bone flap?. World Neurosurg 2016; 88: 569-575
    Google Scholar
  • 10 Nguyen HS, Janich K, Sharma A, Patel M, Mueller W. To retain or remove the bone flap during evacuation of acute subdural hematoma: factors associated with perioperative brain edema. World Neurosurg 2016; 95: 85-90
    Google Scholar
  • 11 Ye J, Zhang W, Ye M. Using titanium mesh to replace the bone flap during decompressive craniectomy: a medical hypothesis. Med Hypotheses 2019; 129: 109257
    Google Scholar
  • 12 Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB. Decompressive craniectomy: technical note. Acta Neurol Scand 2011; 123 (04) 239-244
    Google Scholar
  • 13 Di Rienzo A, Pangrazi PP, Riccio M, Colasanti R, Ghetti I, Iacoangeli M. Skin flap complications after decompressive craniectomy and cranioplasty: proposal of classification and treatment options. Surg Neurol Int 2016; 7 (Suppl. 28) S737-S745
    Google Scholar
  • 14 Neugebauer H, Fiss I, Pinczolits A. et al. Large size hemicraniectomy reduces early herniation in malignant middle cerebral artery infarction. Cerebrovasc Dis 2016; 41 (5–6): 283-290
    Google Scholar
  • 15 Raposio E, Cella A, Barabino P, Santi P. Ineffectiveness of acute scalp expansion. Plast Reconstr Surg 1999; 103 (06) 1645-1649
    Google Scholar
  • 16 Raposio E, Adami M, Capello C. et al. Intraoperative expansion of scalp flaps. Quantitative assessment. Minerva Chir 2000; 55 (09) 629-634
    Google Scholar
  • 17 Raposio E, Bertozzi N. Quantitative difference of acute intraoperative expansion in various body regions. Eur Rev Med Pharmacol Sci 2017; 21 (03) 454-459
    Google Scholar
  • 18 Honeybul S. Complications of decompressive craniectomy for head injury. J Clin Neurosci 2010; 17 (04) 430-435
    Google Scholar
  • 19 Sorano V, Esposito S. Hemispherectomy complications in the light of craniocerebral disproportion: review of the literature and rationale for a filling-reduction cranioplasty. Childs Nerv Syst 1998; 14 (09) 440-447
    Google Scholar
  • 20 Ko K, Segan S. In situ hinge craniectomy. Neurosurgery 2007; 60 (4, Suppl 2): 255-258 , discussion 258–259
    Google Scholar
  • 21 Kenning TJ, Gandhi RH, German JW. A comparison of hinge craniotomy and decompressive craniectomy for the treatment of malignant intracranial hypertension: early clinical and radiographic analysis. Neurosurg Focus 2009; 26 (06) E6
    Google Scholar
  • 22 Adeleye AO, Azeez AL. Decompressive craniectomy bone flap hinged on the temporalis muscle: a new inexpensive use for an old neurosurgical technique. Surg Neurol Int 2011; 2: 150
    Google Scholar
  • 23 Mracek J, Choc M, Mork J, Vacek P, Mracek Z. Osteoplastic decompressive craniotomy: an alternative to decompressive craniectomy. Acta Neurochir (Wien) 2011; 153 (11) 2259-2263
    Google Scholar
  • 24 Hsu YC, Po-Hao Huang A, Xiao FR, Kuo LT, Tsai JC, Lai DM. Decompressive cranioplasty (osteoplastic hinged craniectomy): a novel technique for increased intracranial pressure-initial experience and outcome. World Neurosurg 2019; 124: e431-e435
    Google Scholar
  • 25 Layard Horsfall H, Mohan M, Devi BI. et al. Hinge/floating craniotomy as an alternative technique for cerebral decompression: a scoping review. Neurosurg Rev 2020; 43 (06) 1493-1507
    Google Scholar
  • 26 Akutsu N, Aihara H, Sakurai A, Kusaka J, Yasuda M, Kohmura E. New technique of decompressive skinplasty with artificial dermis for severe brain swelling: technical note. Neurol Med Chir (Tokyo) 2013; 53 (01) 56-60
    Google Scholar
  • 27 Khanna R, Ferrara L. Dynamic telescopic craniotomy: a cadaveric study of a novel device and technique. J Neurosurg 2016; 125 (03) 674-682
    Google Scholar
  • 28 Lyon KA, Patel NP, Zhang Y, Huang JH, Feng D. Novel hemicraniectomy technique for malignant middle cerebral artery infarction: technical note. Oper Neurosurg (Hagerstown) 2019; 17 (03) 273-276
    Google Scholar